Laryngotracheal stenosis: a serious complication of percutaneous tracheostomy

Abstract

SummaryTracheostomy in patients requiring prolonged artijcial ventilation in intensive care is increasingly being performed by a percutaneous dilatational technique, in preference to the standard surgical method. Since its introduction numerous series have reported favourably on its general safety in the short-term, but there have been few reports of longer term follow-up of patients. We present four cases of laryngotracheal stenosis, a previously unreported complication associated with the technique, and discuss the relevance of these to the future practice of percutaneous tracheostomy.

An evaluation of a new percutaneous tracheostomy kit

“…The development aims to reduce potential problems with other methods. Serial dilator methods involve multiple insertions and the associated deforming and traction on the trachea may increase the risk of subsequent stenosis [7]. The Rapitrach method has been associated with tears in the posterior tracheal wall [8] and a possible increased risk of complications [9].…”

Laryngotracheal stenosis after percutaneous tracheostomy

“…It is possible to soften the relatively rigid tube by immersing it in hot water, but this needs prior preparation and may damage the cuff. A previously described technique of using a finger to overcome the obstruction in the nasopharynx may be useful, but is unhygienic [2]. When using a relatively rigid tracheal tube for nasotracheal intubation, we have found a curved gum elastic bougie is helpful in guiding the tracheal tube into the pharynx, thus minimising the obstruction and the trauma.…”

“…Laryngeal, cricoid and tracheal lesions are well described after intubation of just a few days duration [ 11. Ulceration, granulation tissue, exuberant collagen production and eventual healing by stenosis are well described complications of tracheal intubation [2]. Risk factors include size of the tracheal tube relative to the larynx and trachea (size of tubes was not mentioned in McFarlane's reported cases), shape and composition of the tube, inflation pressure of the cuff, movement of the tube within the trachea and intubation trauma.…”

“…Similarly, it was rare for the initial needle entry point into the trachea to be in the midline position. The recent publication [2] describing a series of patients who underwent percutaneous tracheostomy at the subcricoid level, as described by Ciaglia et al [3], and suffered a significant tracheal stenosis has made me sure of the necessity for accurate placement of the tracheostomy at a more classical site. I feel that subcricoid placement is unwise and that the use of a fibrescope can aid good placement of the tracheostomy.…”

“…to a prominent arch of atlas, the hollow above it, adenoids or Passavant's bar [2] may not be overcome by these methods and may result in trauma to the posterior pharyngeal wall including partial adenoidectomy, formation of a false passage, bleeding and sepsis. When using a relatively rigid tracheal tube (e.g.…”